Healthcare Provider Details

I. General information

NPI: 1114699303
Provider Name (Legal Business Name): SOUTH COAST ROCHESTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 UNIVERSITY AVE
ROCHESTER NY
14607-1288
US

IV. Provider business mailing address

58 INDIANA ST
ROCHESTER NY
14609-7437
US

V. Phone/Fax

Practice location:
  • Phone: 585-278-7199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: GEORGE ASHER LEVINE
Title or Position: OWNER
Credential: DDS,MD
Phone: 585-278-7199